125 terms

Andrews Ch 34

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What is the term for a chronic desquamative condition of the lips?
Cheilitis exfoliativa
What diseases are associated with cheilitis?
Seb derm, atopic derm, psoriasis, retinoid therapy, pyorrhea, long term actinic damage, lip licking, irritant or allergic contact derm, Plummer-Vinson, Sjogren, AIDS, protease inhibitors
What are some treatments for cheilitis?
Avoid the cause, Protopic, elidel, low strength topical steroids; petroleum or zinc oxide for fissures
What is the most common cause of allergic contact cheilitis?
Lipsticks; over 90% cases occur in women
T/F: Actinic cheilitis involves the lower lip much more frequently than the upper lip.
True
T/F: Actinic cheilitis often ulcerates.
False; unless carcinoma present
What is the treatment for actinic cheilitis?
Cryosurgery, 5-FU, imiquimod, PDT, CO2 laser, ED/C
What is the diagnosis? Swelling of lower lip with patulous openings of the ducts of glands, with sticky film causing lips to stick together at night.
Cheilitis glandularis: exuberant response to chronic irritation, atopic, factitious, or actinic damage
What is another term for angular cheilitis?
Perleche
What causes angular cheilitis?
Intertriginous dermatitis, usually caused by excessive wetness or dryness, often in elderly with poor denture fit. Often complicated by infection, eg Candida or Staph aureus.
What measurement is typically abnormal in patients with angular cheilitis?
Shortened vertical dimension of the face, leading to drooling
What are some other less frequent conditions associated with angular cheilitis?
Riboflavin deficiency, anorexia nervosa, Down syndrome, intraoral candidiasis (esp in AIDS, DM, chronic mucocutaneous candidiasis), Sjogren syndrome, drug induced xerostomia, atopic derm
What are some treatments of angular cheilitis?
Dental interventions, toical nystatin and Vioform in hydrocortisone ointment, stronger steroids eg Desonide with anticandidal agent, injection of collagen or implants in the creases, mupirocin ointment if Staph present, surgical grafts
What is the diagnosis? Sharply defined red plaque in the mouth, with shiny glaze. Histologically resembles Zoon balanitis.
Plasma cell cheilitis
What is the diagnosis? Verrucous tumor at angle of mouth with plasma cell infiltrate seen on path.
Plasmoacanthoma. May be associated with candida.
Name some drugs that can cause drug induced ulcers on the lip.
Phenylbutaone, chlorpromazine, Phenobarbital, methyldopa, thiazides; Fixed drug eruption seen with naproxen or oxicams.
What chromosomal disorder is often associated with cheilitis of various types?
Down syndrome
What are some of the typical oral findings in Crohn disease?
Swelling or hypertrophy of the mucosa, fissuring/cobblestoning, metallic dysgeusia, gingival bleeding, ulcers, polpoid lesions, fissures on the lower lips, angular cheilitis, granulomatous cheilitis, pyostomatitic vegetans
What % of cases of Crohn disease has oral involvement?
10-20%
Name some other skin manifestations of Crohn disease.
Pyoderma gangrenosum (although more often UC), EN, PAN, pellagra, pernicious anemia, urticaria, necrotizing vasculitis, metastatic disease with noncaseating granulomas
What steroid is used to treat Crohn disease associated with high first pass metabolism in the liver?
Budesonide
What disease is pyostomatitis vegetans most commonly associated with?
Ulcerative colitis
How does pyostomatitis vegetans present?
Edema and erythema with deep folds of the buccal mucosa, pustules, small vegetations, erosions, ulcers, exudates, snail track ulcers with pustules that fuse in to ulcers
What is seen on biopsy of pyostomatitis vegetans?
Dense aggregates of neutrophils and eosinophils
What is the typical course of cheilitis granulomatosa?
Sudden onset of upper lip swelling, then lower lip swelling that progresses and remains permanently
Cheilitis granulomatosa may be the presenting sign of what diseases?
Sarcoidosis or Crohn disease
What is the treatment of Cheilitis granulomatosa?
ILK +/- surgery may work
What is the triad of Melkersson-Rosenthal syndrome?
Recurrent facial paralysis, edema of the lips, scrotal tongue
Where else may you see swelling in Melkersson-Rosenthal?
Dorsal hands/feet and lumbar region, as well as pharynx and respiratory tract
What is the cause of Melkersson-Rosenthal?
Unknown
What is seen on path with Melkersson-Rosenthal?
Tuberculoid granulomas with lymphedema and perivascular infiltrate
What is the differential for Melkersson-Rosenthal?
Ascher syndrome (swelling of lips and eyelids), angioedema, trauma, infections, lymphangioma, hemangioma, neurofibroma, sarcoidosis
What is the treatment of Melkersson-Rosenthal?
None are good, but can try ILK, surgery, antiobiotics, immunosuppressives
What is the diagnosis? Minute yellowish macules and papules on the oral mucosae.
Fordyce spots, can also see on areolae, glans penis, labia minora
What is Meffert's sign?
Lipstick like mark on the rim of glass with hot beverage in Fordyce spots on the lip
What disease may simulate Fordyce spots?
PXE on the labial mucosa
What are the characteristic findings with stomatitis nicotina?
Red dots with white umbilicated papules, with intervening white or raw red areas, on the palate
What is the diagnosis? Asymptomatic, hard protuberance at midline hard palate.
Torus palatinus, can also occur on floor of mouth
What is scrotal tongue or fissured tongue?
Large tongue with deep grooves along middle
What diseases are associated with fissured tongue?
Melkersson-Rosenthal, Down syndrome, can be seen with geographic tongue in psoriasis patients
What diseases are associated with geographic tongue?
Atopy, psoriasis, AIDS, lithium tx, but most often it is an isolated finding
What are the two clinical variants of geographic tongue?
Discrete annular bald patches of red mucosa with absent filiform papillae vs prominent annular or circinate white raised lines
What is the term for geographic tongue when it occurs with psoriasis or reactive arthritis?
Annulus migrans
What is seen on biopsy of geographic tongue?
Marked transepidermal neutrophil migration with pustules in the epidermis, and upper dermal mononuclear infiltrate
What is the treatment of geographic tongue?
Usually not needed, but can try tretinoin solution
What causes black hairy tongue?
Hyperplasia of the filiform papillae on the anterior 2/3 of the tongue, with long filaments of orthokeratotic and parakeratotic cells
What are some predisposing factors for hairy tongue?
Excessive smoking, oral antibiotics, candida
What is the treatment of hairy tongue?
Scrub with toothbrush with peroxide, then apply Retin-A gel, 40% urea solution, or papain
What causes smooth tongue?
Atrophy of filiform and eventually fungiform papillae
What is the term for smooth tongue in association with B12 deficiency?
Moeller or Hunter glossitis
What other conditions are associated with smooth tongue?
Besides B12, pellagra (niacin/tryptophan), malabsorption, riboflavin deficiency, anorexia nervosa, alcoholism, sprue, Plummer Vinson, folate deficiency, syphilis, amyloidosis, Sjogren syndrome, Riley-Day syndrome
What is the diagnosis? 3 year old child presents with fever, refusal to eat, drooling, and cervical LAD. Goes away without treatment in a week.
Eruptive lingual papillitis; likely associated with viral infection
What is the diagnosis? Shiny oval or diamond shaped, red, smooth elevation in the midline tongue. Asymptomatic.
Median rhomboid glossitis
What typically causes median rhomboid glossitis?
Abnormal fusion of posterior tongue, usually with chronic candida infection
What test should you check when you see a patient with median rhomboid glossitis?
HIV
What is the treatment of median rhomboid glossitis?
Oral antifungals, eg itraconazole
What diagnosis should be considered when a patient presents with recurrent eosinophilic ulcers of the oral mucosa?
Primary cutaneous CD30+ lymphoproliferative disease
What is the term for the purple venous lesions on the bottom of the tongue in older people?
Caviar tongue; related to elastic degeneration with aging and may be seen with Fordyce angiokeratomas on the scrotum
What is the diagnosis? Fistula noted on jawline or chin in patient with poor dental health.
Cutaneous sinus of dental origin
What happens if you try to scrape off a lesion of leukoplakia?
It will bleed
Who generally gets leukoplakia?
Men over age 40
T/F: Leukoplakia is a premalignant condition.
False; it can be, but there is a benign form related to chronic irritation. You cannot clinically tell which is which. BIOPSY IT.
What % of intraoral leukoplakia progress to SCC?
Less than 1% per year, or about 6-10% overall, progresses slowly except in transplant pts
Who gets oral hairy leukoplakia?
AIDS pts, a/w virus
Who gets leukoplakia of the vulva?
Postmenopausal, obese women
What are some factors that may be related to leukoplakia?
Tobacco use, areca or betel nut chewing, alcohol, poorly fitting dentures, chipped teeth, poor oral hygiene
Which has a higher rate of malignant transformation: red leukoplakia or white leukoplakia?
Erythroleukoplakia (carcinoma seen in 90% of lesions)
What can be used to stage the epithelial atypia in leukoplakia?
3H-thymidine labeling
What is the treatment of leukoplakia?
Complete removal with fulguration, excision, cryotherapy or CO2 laser
What is the diagnosis? White cauliflower like lesion on the tongue that progresses. May eventually develop SCC.
Oral florid papillomatosis
How commonly does proliferative verrucous leukoplakia develop into SCC?
70%, very relentless with 40% mortality and frequent recurrences
What is the most common oral cancer?
SCC
What is the survival rate for oral SCC?
50%, often discovered late after cervical LN mets
What are some risk factors for oral SCC?
Tobacco, areca or betal nut chewling, alcohol, XP, dyskeratosis congentia, dystrophic EB, erosive LP, oral submucous fibrosis
What is seen on electron microscopy with white sponge nevus?
Aggregated tonofilaments. H and E shows acanthosis, keratinocytes with vacuoles and pink condensations
What is the inheritance pattern and defect in white sponge nevus?
AD, K4 and K13
What is the treatment of white sponge nevus?
Antibiotics/tetracycline
What is the most common type of melanocytic nevi on the oral mucosa?
Intramucosal type, then compound, then junctional nevus
What are some other lesions that present as pigmented lesions in the mouth?
Ephelides (darken with sun, usually on lower lip), lentigines, blue nevus, oral melanotic macules, oral melanoacanthoma, melanoma
How does oral melanoacanthoma present?
Young black patient s on the buccal mucosa, usually reaction to trauma that resolves in 40%
What is the prognosis of oral melanoma?
<5% survival at 5 years due to deep invasion by the time it is discovered
What diseases may be associated with oral melanosis?
Idiopathic process in dark skinned people, Albright syndrome, Peutz-Jeghers, Carney somplex, Laugier-Hunziker, Addison's disease; also consider heavy metal poisoning and drug induced pigment changes.
What should you suspect if you see brownish blue macule on buccal mucosa next to site of dental work?
Amalgam tattoo
What is the diagnosis? Nodule on dorsal tongue that contains bone and resolves after excision.
Osseous choristoma of the tongue
Consider this diagnosis for a neoplasm of the lower gingivae, with biopsy similar to BCC.
Peripheral ameloblastoma
What is the diagnosis? Firm hyperkeratotic nodule on the upper lip of trumpet player.
Trumpeter's wart (can occur on lower lip of trombone player)
What does the term "epulis" mean?
Any benign lesion on the gingival
Name one form of epulis.
Giant cell epulis: solitary tumor that may be induced by dental implants, resembles GC tumor of tendon sheath on biopsy
What is the term for pyogenic granuloma during pregnancy?
Pregnancy tumor or granuloma gravidarum
What is the diagnosis? Firm raised lesion at labioalveolar fold in patient who wears dentures.
Granuloma fissuratum
What is the diagnosis? Sudden blood blisters on the soft palate in older patients.
Angina bullosa haemorhagica
What is the most common cause of mucocele?
Trauma from biting the lower lip; causes rupture of the mucous duct then formation of granulation tissue and fibrosis
T/F: Mucoceles are typically very painful.
False
What is the term for mucocele on the floor of the mouth?
Ranula; a dermoid cyst can also occur on the floor of the mouth
What is the term for cyst on the buccal mucosa opposite the second molar, often in musicians who play wind instruments?
Parotid duct cyst
What is the diagnosis? Rapid onset of punched out ulcers on the interdental papillae and marginal gingivae. Spread rapidly and cause pain, bleeding, and foul odor.
Acute necrotizing ulcerative gingivostomatitis or trench mouth
What are some factors that may be related to the development of ANUG?
Anaerobe infection (Bacteroides, Borrelia), poor dental hygiene, smoking, poor nutrition, ecstasy use, immunosuppression
What is noma?
Fusospirillary gangrenous stomatitis in children with poor nutrition and low resistance, often triggered by measles, can rapidly involve skin and bones and lead to death
What is Takahara's disease?
Acatalasemia, with deficient catalase enzyme leading to progressive gangrene and ulcers in the mouth due to anaerobe infection
What are the 3 types of Takahara's disease?
Mild (recurrent ulcers), moderate (alveolar gangrene with teeth falling out), and severe (widespread jaw destruction)
What is the prognosis for Takahara's disease?
Lesions heal after puberty
How can you diagnose catalase deficiency?
Add hydrogen peroxide to blood and it will turn black-brown without foaming
What is the inheritance of acatalasemia?
AR
What is the treatment of acatalasemia?
Extraction of diseased teeth and use of antibiotics
How long are the cycles in cyclic neutropenia?
12-30 days, average 21
What is the cause of cyclic neutropenia?
Mutation of gene for neutrophil elastase, ELA2
T/F: Cyclic neutropenia is associated with AML.
False; severe congenital neutropenia predisposes to AML but cyclic neutropenia does not
What is PFAPA syndrome?
Periodic fever occurring at regular intervals every 2-8 weeks, aphthous stomatitis, pharyngitis, adenopathy
What is the treatment of PFAPA syndrome?
Small doses of prednisone for 1-2 days, consider tonsillectomy
What is the treatment of cyclic neutropenia?
G-CSF, cyclosporin, antibiotics, good oral hygiene
What parts of the mouth are affected by HSV?
Keratinized/bound to underlying periosteum (gingivae, hard palate, and tongue)
What is the size cutoff for major aphthae?
10mm
Where in the mouth do aphthous ulcers usually occur?
Non-keratinized/not bound to underlying periosteum
Name some factors that may induce aphthous ulcers.
Trauma, self biting, toothbrush injury, dental procedures, spicy foods, citrus, pineapple, walnuts, allergy, emotional stress, hormonal changes
How common are recurrent aphthous ulcers?
10-20% of the population
What are some treatments for aphthous ulcers?
Benadryl/Maalox mixture, viscous lidocaine, dyclonine topical anesthetic, fluocinonide or clobetasol with orabase, ILK, oral steroids, tetracycline suspension, aphthasol, sucralfate, dapsone, colchicines, thalidomide
What patient population often gets major aphthous ulcers?
HIV
What are the criteria for diagnosis of Behcet syndrome?
Recurrent oral aphthous ulcers 3x/year plus 2: recurrent genital ulcers, retinal vasculitis, anterior/posterior uveitis, skin lesions, positive pathergy test
What areas of the world have a relatively high prevalence of Behcet syndrome?
Far East and Mediterranean
What is seen on biopsy of Behcet syndrome?
Early lesions show LCV, later lesions show lymphocytic perivascular infiltrate with obliteration of endothelial lumen
What is the usual presenting sign of Behcet syndrome?
Oral ulceration
How do you do a pathergy test?
Inject 0.1ml of saline into skin or prick with needle and a pustule forms in 24 hours
What other diseases show positive pathergy test?
Pyoderma gangrenosum, Sweet syndrome, bowel-associated dermatosis-arthritis syndrome
What are the potential serious complications of Behcet syndrome?
Blindness, neurologic impairment, vascular thromboses
What are some treatments for Behcet syndrome?
Colchicine, dapsone, thalidomide, MTX, other systemic immunosuppressants